The claim adjuster’s main role is to get an injured worker rehabilitated and back to work. The timeline on how this can happen depends on a multitude of factors, including the severity of injury, age of patient, prior injuries to same area, the diagnosis, and what the person does occupationally for a living. It is safe to assume a person who paints ceilings does a lot of overhead work. And if this person has 2 really bad shoulder surgeries, this worker is not going to be painting ceilings anymore.

Severe injuries and bad claims are going to happen. Sometimes there is no way around them. The main focus for risk management should be on the day to day, normal, medium-exposure lost time claims and how to save money on them. These are claims that have maybe 6-12 weeks of disability. These are the prime claims to be aggressive with and stop bleeding wasted claim dollars. (WCxKit)

But, a lot of the responsibility lies with the employer. The employer controls a lot of the future for the injured worker. Here are 7 excuses adjusters hear from employers when the adjuster wants to get injured workers off of work comp pay and back to work making either the normal wage, or a modified one, depending on the program outline.

1. No light duty work available

This is always the easiest excuse. A certain way to stop an injured worker from returning is to say you do not have anything for them to do within the medical restrictions. This is OK, if you want the employee to hang out at home and watch TV and make a good percentage of the gross pay. But the point is to stop that from happening. Create a job for this worker to do. Granted, not every employer has light duty work. Smaller shops are at a disadvantage since the number of tasks to do can be limited, but be creative. Have them do some painting. Let them sweep outside. Have them plant flowers. Chances are employers can find something for the injured workers to do.

2. Afraid of aggravating the injury

Another great excuse is “I am afraid my injured worker will aggravate the injury when returning to work.” Sure, that is a valid concern. But the worker could be injured worse by falling down at home, by falling in the grocery store, or by falling out of a fishing boat. Whatever the risk may be, it is everywhere not just at the plant. So that is a very weak excuse. Yes the risk is there, but not if you as the employer plan accordingly, and be smart about putting the worker back on light duty.

3. Afraid of new injury

“What if the employee slips or falls? I am afraid of having the worker here while hurt. The employee could hurt something else and be off even longer.” Another classic excuse. Yes, that is correct. That could happen. But again that could happen anywhere. If the injured worker has a knee injury, do not have them working outside by the loading docks while it is raining so they have a risk of slip/fall. It comes down to common sense. Have the claimant do something safe, and easy to do. The point is not to have them riding the edge of risk everyday until full duty resumes.

4. Afraid of the injured worker hurting someone else

And the third one in the series of “I am afraid” is the injured worker injuring someone else. And yes that is also possible. But again, use that common sense when reviewing these light duty prospective jobs. Customize them to the injured worker to minimize risk of injury. Stop those claim dollars on lost wages from going out the window for no reason.

5. Injured workers cannot be productive

This one is a more direct assertion. This is so variable I do not think I have enough room to talk about it. It comes down to customization of the job to the injury. If the worker has a hand injury, I do not think the employee should be packing boxes and taping them while also carrying them out to the loading dock. A guy with an ankle injury should not be running parts and materials back and forth across the length of your factory. Everyone can be productive if the circumstances are favorable to what the strong points are. If the machine operator is injured and cannot run the machine, but you know he has a knack for inventory and ordering parts, let him do that. Be creative.

6. No job description

A personal favorite is when the employer states they do not have a job description to send to the doctor to get work restrictions. Of course you know what that person does for a job as an employer overseeing that employee for what maybe 17 years. To the adjuster, that translates in to “I do not feel like typing out what he does in an email.” The carrier/TPA cannot “force” the employer to do anything. It comes down to your own commitment to the program to save money. Every little bit will count, and every little bit will go towards that main goal of saving “x” by the end of the year . But you have to put the time in to get the benefit out of it. And, an employer could visit the employer's facility yearly to observe all jobs.

7. Do not want to pay the worker the full wage to do a light duty job

Some welders for example that make a ton of money per year get paid the normal wage to answer a phone. That is a pretty good job to have! Remember, in most states you do not have to pay them the full wage. The employer can pay them what they would have made being off on workers compensation. Now that is a bit of a low-blow to the worker, but if you want to be that tight about your program then you can run it that way. Or, better yet drop their pay down to “x” per hour to do light duty, and let your carrier/TPA pay the worker a partial wage check. It is better than the worker sitting at home and getting full workers comp pay. This way, the employee is on light duty work for 2-4 hrs. per day, the carrier pays the rest, and the employer looks like a genius by how much this will save in the long run. (WCxKit)

Summary

These are only some of the excuses heard to avoid a proactive transitional work program. At the end of the day, it is your job as the employer to set the tone for being proactive. Team up with your HR dept. and make those job descriptions. Be creative about light duty work and what a person can do, then base a wage on it. That does not mean your welder that makes $35/hr. always has to make that high of a wage. In light duty, maybe drop the rate across the board and if someone is owed a partial compensation wage check then that is okay. It is still better than letting the injured worker control the claim, since the only job would be to check the mail for a compensation check.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50%www.WCManual.com.Contact: RShafer@ReduceYourWorkersComp.com.

Given recent economic turmoil, many are having a hard time meeting financial obligations. This especially rings true for injured workers, who already have a strike against them — they are receiving workers compensation wage loss benefits at 66 percent to 80 percent of their previous income, and they are injured.

The situation worsens when an injured worker faces situations such as elimination of their job, permanent physical restrictions, or a long recovery after a major surgery. These factors mean pending workers compensation claims are being held open much longer, inflating claims counts for adjusters across the board.(WCxKit)

Below, are five situations that contribute to delays in closing workers compensation files:

Claimants trying to milk the system.

In the minds of most injured workers, having some money coming in is better than having no money coming in. The injured worker may not have a job to return to or may fear termination because of an on-the-job injury, so they maximize the symptoms of their injury; this is called malingering.

Whatever the reason, a current trend involves injured workers stretching claims out as long as possible. Some purposefully take longer to recover by doctor hopping, trying non-conventional forms of treatment, and exaggerating pain complaints. The length of time out of work must be proportionate to the degree of disability.

Most physicians will catch this and mention something in medical records, which should alert the adjuster to set an independent medical evaluation (IME) or to do some surveillance on the file. Using the MDGuidelines is also helpful; since that offers a range of times a worker should be approaching maximum medical improvement (MMI). If the worker is not back to work within the guidelines, it is time for an IME. Be proactive on the claim or the months will continue to go by and the claimant will achieve their goal.

Injured workers have no job to return to for light duty, let alone full duty:
As mentioned above, a common scenario for an extended compensation claim is when the position the worker was in is eliminated, or when the employer does not have a transitional duty program. Since the job market is tight, some injured workers let their accepted workers compensation claim go on as long as possible.

Employers should alert adjusters before job cutbacks so they can discuss strategy on who will be affected. The adjuster can form an action plan to get the claimant back to full duty without letting him or her slip through the cracks.

Claimants choose to litigate because they have no other choice and nothing to lose:

When claims are denied, workers may think they have nothing to lose by filing for a hearing or seeking counsel. This causes the claim to be open for several months or years while the litigation ensues and parties work toward an eventual settlement. The wheels of the legal system often move slowly, and this contributes to the number of open claims out there. If you take a slow-moving legal system and overload it with everyone filing for a WC claim hearing, you get a backlog of claims and the system barely moves. Stay in touch with counsel to make sure he or she is trying to settle the claim and move negotiations forward. The very best way to avoid litigation is to communicate with the employees. Have an employee brochure, a written transitional duty policy, have employee’s acknowledge receipt of the policy, have a brochure for your network physicians, and most importantly have an Injury Treatment Medical Information Form, a/k/a Work Ability Form. THIS gathers information from the injured employee’s doctor at the first medical visit. Employees contact attorneys because they can’t get information from their employers about their claims or their medical bills are not paid.

Claimants have severe injuries:

Due to company cutbacks as mentioned above, one worker may be doing the work of three. This leads to employers trying to do more with less. Injuries are bound to happen, especially in more heavy-duty, manual-labor positions. Employees working longer hours and doing more strenuous activity are leading toward a musculoskeletal injury and a probable surgery, if not worse.

These workers may be reluctant to report an injury for fear of losing their job. So they try to work thorough the pain, until the injury gets so bad it needs immediate attention. Workers need to know to promptly report injuries no matter what the circumstance, so they can be treated before it gets worse. Workers with wrist pain wait until they have full-blown carpal tunnel before reporting the pain; whereas if it had been reported sooner, full recovery would have been more rapid and less traumatic; waiting is prevalent when pay is conditioned on production-based pay.

Some injured employees wait for the Centers for Medicare and Medicaid Services (CMS) to approve the Medicare Set-Aside (MSA):

The dreaded MSA. If an injured worker is eligible for Medicare and the case is in litigation or parties want to settle, in order to settle the claim, an MSA is necessary. This will pay the employee what Medicare would have paid for the continued treatment of the injury. The employee then pays for future treatment from this account. He or she then files paperwork with CMS that tracks the claimant’s continued medical treatment long after the workers compensation carrier settles.

Getting CMS to approve an MSA can take from eight months to two years as there are numerous payment issues to be ironed out. Carriers and CMS employees are adjusting to this new system and, so far, it has not been a smooth transition, according to Gould and Lamb, experts in MSA issues. An adjuster or counsel can further explain how this works in individual jurisdictions.(WCxKit)

In summary, workers compensation claim closure rates have slowed nationwide with multiple forces to blame. But, with a good action plan, some persistence, and a bit of patience, these issues can be resolved and the file can eventually be closed for good.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

When you have a high-exposure file that turns out better than you had expected and costs come in way under what you had budgeted for, it is easy to see the cost-savings that are associated with that loss. If you saved $50,000, that’s a nice lump of savings for your balance sheet.

But those little savings you make throughout the course of a year add up as well. It’s difficult to see it in the short-run, or by the month, but looking at it over the course of a year, it can really add up to a nice savings in your budget. We discuss some ways those little savings can add up below. (WCxKit)

1-Using quality vendors to get better results:

Sometimes the better vendors just cost a bit more than others. This is usually due to the fact that they have better talent working for them, and there are associated costs included with that. However, if these more expensive vendors get your workers back to you ready for work quicker, then you save again on the wage loss issue. This means that these vendors have already paid for themselves if you weigh their costs versus the cost of wage loss for your injured worker. Talk with your carrier about who the best vendors are in your area for IMEs, surveillance, and nurse case management. Don’t shy away from them just because their costs are a tad higher than their competition. They can save you money in the long run by providing you with excellent service, and by getting those injured workers back to work quicker than their counterparts.

2-Enhanced communication with your TPA/Carrier:

Lack of proper communication can lead to increased claims expense. If the adjuster doesn’t know that you have light duty work available, they may not be pushing hard enough to get work restrictions for your injured worker. Maybe the adjuster doesn’t know you have a dedicated medical clinic and/or physical therapy facility and failed to direct the injured party to treat at those clinic locations.

Maybe the injured worker took vacation time or sick pay for their time off of work, and they didn’t tell the adjuster that so they got paid twice-once by your company and once by the Carrier. Although most times the adjuster will catch this, sometimes they do not. This leads to an overpayment that the carrier must try to recoup, and if they fail to do so the cost of that ultimately gets pushed to you in the result of a higher premium due to increased claim costs. Whatever the event may be, you need to be in regular contact with your adjuster.

Perform claims reviews and ask the adjuster on each claim what their plan is for getting the claim resolved. The more you discuss the claim, the more ideas you both can come up with, and that may be what is keeping your worker off of work. By working together, you will save costs. Most adjusters would prefer too much communication versus not enough, plus this will keep the adjuster on their toes and they will be keeping a close eye on your claims, preventing one from falling through the cracks which will further waste claims dollars.

3-Using the other departments your TPA/Carrier has to offer:

Most Carriers/TPAs have multiple departments that will work with you to reduce your exposure. Loss prevention, ergonomics, dedicated adjusters to your account, medical/nurse resources, medical bill review, etc. All of these services may be provided free of charge by your Carrier/TPA, and the end result of utilizing these services will be lower claim cost to you. Implementing the action plans that these departments come up with is designed to lower your costs. So talk with your Carrier/TPA and find out what resources they have to help you reduce cost. They will be happy to work with you, and you will be happy since your claims expense will decrease over the course of a year.

4-Utilizing a 3rd party company for all of your RX needs:

Pharmacy costs are constantly rising. Almost every injured worker comes out of their doctor's appointment with a prescription for some medication in their hand. There are a lot of 3rd party pharmacy companies out there willing to work with you to reduce these costs if you funnel your injured workers to their pharmacy programs. Find out what kind of pharmacy management program they provide. The best sell their services unbundled. Look for prospective as well as retrospective elements of the cost control program. This can lead to huge cost savings, even on the minor claims, and will help the most with the more severe claims, since those injuries usually require prescriptions that cost more, and they length of the prescriptions last longer. This is a significant way to reduce your costs, and you will see large savings at the end of the year. (WCxKit)

Summary:

There are a lot of ways to reduce your costs. Not only in the larger higher exposure claims, but in the small minor claims as well. If you think about it, every little savings you can make can add up to a lot by the end of the fiscal year. Remember there are ways to cut costs on every claim, no matter how insignificant the claim may be at the time. You have to think both ways, in the short term and long term. Whatever it may be, the end result is you saving money, and that is never a bad thing

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

The challenge: A grey zone medication is any type of drug for which special attention is required to determine if it is appropriate for the injured worker based on compensability, relation to injury and medical history. Ensuring medications are appropriate has become increasingly complex due to an aging and unhealthy workforce. Workers who have more simultaneous ailments are leading to the use of medications that are unrelated to the actual injury.

By working with a pharmacy benefit manager (PBM), payors can create medication plans that are based on specific criteria to ensure that medications are appropriate for the injured worker. Medication plans should be specific to body part and nature of injury, as well as the acute or chronic nature of the injury. PBMs should also offer electronic notification of approved and misaligned medications. This will reduce administrative burdens on claims professionals, allowing them to focus on jurisdictional issues related to the claim while the PBM can focus on medication concerns.

Establish comprehensive utilization management programs

Utilization management programs are essential to limit cases of fraud, misuse and abuse and ultimately ensure injured worker safety. A quality program should include working with a clinical staff capable of performing in-depth, injured worker-specific drug utilization reviews. While PBMs offer utilization review programs, payors should also ensure their partner has a process in place that is managed by clinical pharmacists. The clinical utilization review program should use a combination of evidence-based medical guidelines, peer review journals and recommendations provided by government organizations.

·Prospective utilization reviews– A prospective program allows all involved parties to plan for future outcomes with up-front information. Guiding future decisions through historical data and practices allows for the achievement of cost control and utilization control.

·Concurrent utilization reviews– A concurrent program can prevent abuse involving the use of multiple pharmacies and physicians for different medications, or excessive early refill attempts. The PBM can trigger concurrent alerts to inform the dispensing pharmacist about possible reasons a medication should be questioned before filling. This process can ensure that prescriptions are not filled at the point-of-sale unless the medication is allowed or the PBM receives authorization from the payor.

·Retrospective reviews– After a prescription is filled, the PBM’s clinical pharmacist team should audit the claim for indicators of misuse; multiple physicians, duplication of therapy, excessive duration and use.

. Clinical intervention programs– Seek a PBM that offers a wide range of clinical intervention programs to assist with evaluation needs. The range of programs should consist of registered pharmacists, nurses and other health professionals available for consultation on medication questions and peer reviews. The PBM’s clinical intervention team should provide recommendations for specific claims that require further evaluation.

Physician monitoring

It is essential to have a process that monitors an injured worker with multiple physicians. A successful program should be based on established best practices and contain multiple components including:

Monitoring for appropriate medication utilization using evidence-based published therapeutic guidelines

Overseeing prescribing patterns at the physician level to establish appropriate/inappropriate use of brand name medications when an FDA approved generic equivalent exists

Participating in mandatory and voluntary state reporting programs that monitor for excessive prescribing patterns

Pharmacist support

The PBM must have a staff of clinical pharmacists available to provide customized support for medication-related decisions. The exchange of medication education between pharmacists and claims professionals is important for both general and injured worker-specific information.

Nursing support

A more holistic clinical picture of the claim should be obtained by the claims professional. Nurses on an experienced clinical services team are uniquely positioned to assist in explaining the details on medical service claims. Having access to experts in non-drug therapy can allow the claims professional to make more informed decisions.

Claims professional education

Effective seminars that train and provide guidance to claims professionals on the payor’s policies for managing grey zone medications should be provided. These sessions should be included within claims professional’s regular education and training,

Summary: Managing medication utilization for injured parties has become increasingly complex for workers compensation payors. As new medications become available, the workforce continues to age and medical histories increase in complexity, navigating the grey zone medication maze will remain a challenge. By putting best practices into place to manage the appropriateness of medications, payors will ultimately ensure injured worker safety while reducing opportunities for fraud, misuse and abuse.

For more detailed information on the definition and classification of grey zone medications and common grey zone drugs please visit Progressive Medical’s Grey Zone Resource Center.

Author Tron Emptage, who holds a BS in Pharmacy, is Chief Clinical & Compliance Officer with Progressive Medical. Mr. Emptage has overseen Pharmacy Services, Clinical Services, National Account Management served as Vice President of Strategic Initiatives and Executive Vice President of Business. His 20-year plus experience in pharmaceutical and managed care defines him as a key player in moving the company forward in the arena of national pharmaceutical managed care. Contact him: tron.emptage@progressive-medical.com or 800.777.3574 or visit Progressive Medical.

About Progressive Medical

Progressive Medical offers cost management services and programs to the workers compensation industry. By combining its clinical expertise with access to an expansive network of pharmacies, home health care services and medical equipment and supplies, the company enables its clients to manage costs while providing quality care to injured workers. Learn more at Progressive Medical or call 866.939.5365. http://www.workcomptransformation.com/narcotics-quandary/

The debate over bundled program services vs. unbundled program services is often a matter of perspective. For readers wondering what we mean, bundled program services are when the self-insured employer gets all claim handling services from one service provider. Unbundled is when the self-insured employer gets claim handling services from multiple providers.

In addition to claims-adjusting services, there is an array of auxiliary services the self-insured employer will need. These include medical triage, physical therapy, nurse case management, medical bill review, pharmacy benefit manager, special investigations unit (SIU), defense attorneys, risk control/safety services, and data management services. In the bundled program, a single third-party administrator (TPA) will provide all claim handling services to the self-insured employer, while in the unbundled program, the self-insured employer will be dealing with several service providers besides the TPA providing the claims adjusting.(WCxKit)

When an account executive for an insurance broker’s office and an account executive for a large TPA (with all the various services available) talk to a self-insured employer’s risk manager, account executives will place the emphasis of their sales pitch on the convenience of having one TPA administer everything, the seamless coordination of all aspects of claims handling, and the economies of scale having the multifaceted TPA handle everything.

When an account executive of a small TPA delivers a sales presentation, emphasis is placed on the better price o be provided without all the large TPA overhead, along with the personalized attention their adjusters and other employees will provide.

Neither the large nor small TPA will mention leakage (the money you will spend unnecessarily) by having either the bundled program approach or the unbundled program approach. Both approaches have flaws and the account executives for both the bundled and unbundled programs will often not realize the leakage their company’s approach to claim services cost the self-insured employer.

Leakage in the bundled program often results from the fact that it is a bundled program. Without precise guidelines (which account executives definitely do not want), it is way too easy in the bundled program for an adjuster to assign a nurse case manager on a claim where the adjuster could make the same few phone calls to find out an employee’s medical status. It is also too easy for the adjuster to refer a claim to the SIU then to take necessary recorded statements from the employee, the employee’s supervisor, etc. When a self-insured employer is paying a nurse case manager, the pharmacy benefit manager and the SIU to make phone calls the adjuster should have made, you can have major unnecessary claim-handling expense leakage.

Another leakage source in the bundled programs is often service cost. If the in-house nurse case manager at a large TPA charges $10 more per hour for the same nurse case management services than the small independent provider of medical management services — that is leakage. All charges to the self-insured employer may be valid, but if the nurse case manager puts in 50 hours of work over the life of the claim, an extra $10 per hour amounts to $500 in leakage.

Leakage also occurs with unbundled programs. If a TPA has to contact an outside vendor for the claim handling services needed, any communication or follow-through delays can become leakage. For example, if a TPA adjuster has to wait on approval to employ a nurse case manager or an outside surveillance company, a two-day delay is two extra days of indemnity benefits. That may not sound like much, but if the same nurse case manager the adjuster hired recommends a change in medical care and the adjuster has to obtain his supervisor’s approval another day is lost. Again it does not sound like much, but the cumulative affect of delays in an unbundled program can bring substantial additional cost.

Another aspect of the unbundled program to avoid is delegating to the adjuster the responsibility of hiring other vendors . Other vendors in an unbundled program should be designated by the self-insured employer. If not, the adjuster hires his golfing buddy to do surveillance on the claimant with the questionable injury. Or, the adjuster may hire the defense attorney who has the best Christmas party, not the best defense attorney for your work comp claims. When the adjuster is also given the responsibility of reviewing and approving vendor service fees when the adjuster has chosen them herself, the adjuster could be more lenient, resulting in additional leakage through higher-than-necessary service bills.(WCxKit)

Whether the self-insured employer uses a bundled services approach or unbundled services, it must remain the priority of the self-insured employer to closely scrutinize all service costs to be sure the services are being provided in the most cost-efficient manner and that claims leakage does not occur.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

Safety National policyholders will receive free access to the Workers Comp Kit as part of their relationship with the company. For buyers of insurance, brokers and agents, and other insurance organizations, Safety National has partnered with Advisen to service and support all other parties utilizing this software to help ensure the Workers Comp Kit retains and grows its reputation for reducing workers compensation expenses.

“As the nation’s leading provider of excess workers compensation solutions, we are thrilled to add this tool to the Safety National arsenal as the Workers Comp Kit has clearly become a proven way to lower post-injury cost drivers for our clients,” said David Snodgrass, director – risk control services at Safety National. “Purchasing this program is consistent with Safety National’s philosophy of working in partnership with our policyholders to help lower claim costs.”

Ed Forer, executive vice president at Advisen, elaborated, “The Workers Comp Kit addresses a need that buyers and brokers repeatedly tell us must be met. We are excited to help risk managers develop a consistent approach to managing post-injury procedures at their various business locations, which ultimately saves them money.”

Many employers face growing workers compensation expenses and are placing greater reliance on brokers and insurers to help reverse the trend. The Workers Comp Kit enables an employer, broker and insurer to work collaboratively to improve best practices and reduce expenses. This program’s applications combine interactive tools to perform assessments, highlight areas for improvement, make recommendations, create plan implementations and monitor their post-injury performance.

Safety National is a versatile alternative market insurance provider offering a broad range of risk funding products through independent insurance agents and brokers. Founded in 1942, Safety National is the leading provider of Excess Workers Compensation coverage to self-insured employers and groups nationwide and has provided that type of coverage longer than any other company in the U.S. In addition, Safety National offers its Large Casualty Program, which includes Large Deductible Workers’ Compensation, Commercial Auto and General Liability coverage; Public Entity Multi-Line coverage; Treaty Reinsurance; Loss Portfolio Transfers (LPT); Texas non-subscriber coverage (TEXcess); Self-insurance Bonds and other alternative risk programs. The company is licensed to provide workers’ compensation insurance in all 50 states, the District of Columbia and Canada. Safety National is a wholly owned subsidiary of Delphi Financial Group Inc. (NYSE: DFG) and is rated “A” (Excellent), Financial Size Category XI, by A.M. Best. www.safetynational.com

Advisen’s data, analytics and news offerings are game-changers for 100,000 commercial P&C professionals. Advisen integrates business information and market data for the commercial insurance industry and maintains critical risk analytics and time-saving workflow tools for over 530 industry leading firms. Advisen delivers actionable information and risk models for Underwriters, Reinsurers, Brokers and Risk Managers at a fraction of the cost to have them built internally. Designed and evolved by risk and insurance experts, Advisen combines the industry’s deepest data sets with proprietary analytics and offers insight into underwriting, marketing, broking and purchasing commercial insurance that is not available on any other system. www.advisen.com

In Florida, every employer who has four or more employees, whether full time or part time, is required to carry workers compensation insurance. Corporate officers who have elected to exempt themselves from work comp coverage do not count as an employee, however. There are a couple of exceptions to this rule.

If you are in the construction industry and have one or more employees, you are required to have work comp coverage. Florida farmers who have more than five regular employees, or twelve or more seasonal workers who are employed for 30 days or more, are required to have work comp coverage.(WCxKit)

4 Ways to Obtain Coverage:

To obtain workers compensation coverage in Florida, the employer has several options including:

3.Contracting with a professional employer organization (employee leasing) that has a group workers compensation policy.

4.Purchasing a workers compensation insurance policy from the Joint Underwriting Association, a Florida state agency that sales workers compensation insurance coverage to employers who are unable to obtain coverage in the open market.

Claim Reporting:

The employee must report the injury to the employer within 30 days of the occurrence. If the injury is not reported in a timely manner, the insurance carrier has the option to deny the claim. The employer is under a strict time limit of seven days to report the claim to the insurance carrier. The insurance company then has three days to send an informational brochure to the employee outlining the employee's rights and responsibilities under the workers compensation statutes.

Medical Benefits:

The employer selects and authorizes the initial medical provider. All subsequent medical treatment must be at a medical provider approved and authorized by the workers compensation insurance carrier. All authorized medical care and associated expenses (prescriptions, prostheses, mileage reimbursements) are covered by workers compensation.

Temporary Total Disability Benefits:

The temporary total disability (TTD) benefits are calculated as two-thirds of the employee's average weekly wage over the 13 weeks prior to the injury, not counting the week the injury occurred. The maximum amount of TTD benefits that can be paid weekly changes every Jan. 1. The maximum TTD benefits per week for accidents occurring in 2010, was $772. The maximum TTD benefits per week for 2011 is $782. The state minimum weekly benefit is $20, which has not changed since 1972.

The first 7 days of disability (the waiting period) is not paid to the injured employee unless the employee is disabled for more than 21 days. TTD benefits can be paid for a maximum of 104 weeks. There is no provision in Florida law that requires the employer to hold open a job for an employee who is unable to work. (Holding the position for the employee is the smart thing for the employer to do in most cases.)

Temporary Partial Disability Benefits:

Florida work comp also provided for temporary partial disability (TPD). An employee will receive TPD if the medical provider releases the employee to work with restrictions on the number of hours the employee can work. If the employee is unable to earn 80 percent of his wages prior to the injury, the insurance carrier will pay TPD benefits on the hours the employee is unable to work per week.

This is when the employee has been released by the authorized treating physician to return to work in any capacity. The payment is then 80 percent of the difference between 80 percent of the employee's AWW and earnings. This is referred to as the 80/80 formula. If work is available within the employee's restrictions and the employee does not return to work then no benefits are payable.

Impairment Benefits:

When an employee reaches maximum medical improvement, the medical provider will determine whether or not the employee has any permanent partial disability. If the employee receives a permanent impairment rating, a scale is used to establish the number of weeks of compensation the employee is entitled to.

The employee will receive:

1.Two weeks for each percentage point of impairment from 1 percent through 10 percent

2.Three weeks for each percentage point of impairment from 11 percent through 15 percent

3.Four weeks for each percentage point of impairment from 16 percent through 20 percent

4.Six weeks for each percentage point of impairment from 21 percent and up.

If the employee is earning the pre-injury wage or higher, the benefits are reduced by 50 percent.

Permanent Total Disability Benefits:

Florida has a unique way of determining if an employee who has reached maximum medical improvement has a permanent total disability (PTD). If the employee can be placed in a sedentary job within 50 miles of his residence, the employee is not PTD, unless he has a severe injury as defined by the Florida work comp statutes.

Some of the severe injuries include spinal cord injuries that involve paralysis of an arm, leg or the trunk; amputation of a hand, arm, foot, or leg; severe brain injury; and, second or third degree burns over 25 percent of more of the body. If the employee is classified by the Division of Workers Compensation as PTD, the employee will receive PTD benefits which are the same as TTD benefits until the age of 75. If an employee is drawing social security benefits, the PTD benefits are reduced to the point where the social security benefit plus the PTD benefit equals 80 percent of the average weekly wage earned prior to the injury.

Death Benefits:

If an employee dies as a result of an on-the-job accident within one year of the date of the accident, or if the employee dies as a result of an on-the-job accident within five years with continuous disability, funeral expenses up to $7,500 is covered by workers compensation. The spouse is entitled to 50 percent of the average weekly wage, not to exceed $782.00 (for calendar year 2011).

The spouse plus one child is entitled to two-thirds of the average weekly wage, not to exceed $782 (year 2011). If the employee leaves behind one child as the only beneficiary of death benefits, the child receives one-third of the average weekly wage, not to exceed $782 (year 2011). There is no time limit on how long benefits can be paid, but the maximum amount of death benefits is $150,000 (not including funeral expenses). If the spouse remarries, the spouse receives a lump sum payment of 26 weeks as long as the $150,000 cap is not exceeded. The spouse is also eligible for tuition benefits at a vocational technical center or community college.(WCxKit)

Vocational Benefits:

If, due to the employee's on-the-job injury, the employee is unable to return to work because of permanent work restrictions, the employee is entitled to assistance from the Workers Compensation Vocational Rehabilitation Section of the Florida Department of Education. At no cost to the employee, the employee can receive vocational counseling, transferable skill analysis, training on job-seeking skills, job placement, on-the-job training, and formal retraining.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

Texas often leads the nation in workers compensation cost containment and narcotics legislation. The state recently continued their history of reform by adopting a new pharmaceutical formulary that will reduce the amount of money spent on workers compensation medications and improve the overall health of the state's employees. How does it work? What can you do to remain in compliance?

Broadspire is conducting a webinar to provide answers about the new Texas formulary August 23. Speaking on compliance issues was formulary co-creator Ralph Kendall, PharmD., vice president of clinical services at Healthesystems.

Also Jacob Lazarovic, MD, chief medical officer at Broadspire, will discuss the clinical implications of the formulary and Lynn Sergeant, RN, team manager of utilization management at Broadspire, will be discussing how Broadspire is operationally responding to the formulary.

For 4 p.m. Aug. 23, either click the following link or copy and paste it into your Web browser:

Washington State is one of the four remaining monopolistic states (where the state government is the insurer rather than private insurance companies). In the November 2, 2010 election, there was a measure on the state ballot to privatize Washington’s workers compensation system, but it was rejected by the voters.

Compulsory Coverage

Employers with one or more employees must have workers compensation insurance for the employee(s). Sole providers, partners, corporate officers, and the manager of a limited liability company may elect to exclude themselves from the workers compensation insurance coverage requirements. Workers compensation coverage is not required for a newspaper carrier, a beautician or barber renting booth space, a child under age of 18 employed on the family farm, a domestic or gardener for a private home as long as only one person is employed, and a person working for a religious or charitable organization in exchange for sustenance. (WCxKit)

Obtaining Coverage

To obtain workers compensation coverage in Washington, the employer has two options which are:

1.Participate in the state monopolistic workers compensation insurance program administered by the Washington State Fund in the Department of Labor & Industries.

2. Meet standards set by Washington State to be a self-insured employer. (About 400 employers in Washington are self-insured, but they are the largest employers covering between one-fourth and one-third of the total workforce.)

Claim Reporting

The employee must submit to Department of Labor & Industries or the self-insured employer a claim application within one year of the injury or within two years of the doctor’s diagnosis of an occupational disease. The medical providers of employees covered through the State Fund are required to submit the Report of Industrial Injury or Occupational Disease. The medical providers to employees of employers who are self-insured are required to submit to the employer the Self Insurer Accident Report. If the employee is unable to return to work, the physician is required to submit the Activity Prescription Form.

Cost of Workers CompensationWashington is the only state that allows the employers (who purchase workers compensation insurance from the State Fund) to deduct a part of the cost of workers compensation from the employees’ wages. The employer can deduct up to half of the cost of the premium portion that pays the medical benefits and the portion of the premium that pays the cost of living increases for the injured workers drawing life-time compensation benefits – known as pensions. Employers must pay the entire portion of the premium that is used to pay lost time compensation and pensions. Overall, employees pay approximately 27 percent of the total work comp premium to the state.

The employee selects the medical provider of their choice. If the employee is not satisfied with the medical care provided, the employee can change doctors at will. If the employee is not satisfied with the medical recommendations of the selected medical provider, a second opinion can be obtained if approved by the claims administrator.

All reasonable and necessary medical care is covered by workers compensation. There are no time limitations or monetary limitations on the medical benefits. All billing of medical services by medical providers must be in compliance with the fee schedules published each year by the State Fund.

Temporary Total Disability (TTD)

When an employee in Washington State is certified by the medical provider as unable to return to work, the State Fund or the self-insured employer will pay TTD. The compensation rate varies from 60% to 75% of the gross wages, depending on the employees martial status (or registered domestic partnership) and how many dependents the employee has (60% for the employee, 5% additional for a spouse, and 2% additional for each additional dependent, up to 5 additional dependents).

The maximum amount of TTD benefits that can be paid is 120 percent of the state average monthly wage. The minimum amount of loss time compensation benefits that can be paid is 15 percent of the state average monthly wage. The maximum amount had been recalculated each year, with the new rate going into effect on July 1st. On June 5, 2011 a one-year freeze on time loss benefits was signed into law. The TTD benefit maximum for July 1, 2011, through June 30, 2012, will be the same as the previous year. The monthly dollar maximum TTD benefit for July 1, 2011, through June 30, 2012, is $4,715 and the monthly minimum TTD benefit is $185.

The first 3 days of disability (the waiting period) are not paid to the injured employee unless the employee is disabled for more than 14 days. TTD benefits can be paid for as long as the medical provider keeps the employee off work.

The Stay-at-Work Program instituted by the Labor & Industries office effective June 15, 2011 is taking a very proactive approach to providing modified duty to injured employees. In the new program the Labor and Industries office will reimburse employers for half of the worker’s wages while the employee is on working on modified duty. The Stay-at-Work Program is designed to speed workers’ recovery, prevent long-term disability, and reduce cost for both the State of Washington and for the employer.

Permanent Partial Disability Benefits

Washington State employees are paid permanent partial disability (PPD) benefits for any permanent disability suffered as the result of an on-the-job injury. Washington State uses a schedule of injuries for limbs, vision and hearing. The total loss of a body part is worth a set dollar amount stated in the schedule. A partial loss is paid as a percentage of the set dollar amount.

For non-scheduled injuries, the maximum period of payments is not specified. The maximum dollar amount for permanent partial disability is currently (February, 2011) $149,116 but subject to change each July 1st. Payments are based on a percentage of disability.

Permanent Total Disability (PTD)

The amount of indemnity compensation for PTD is calculated the same as for TTD. PTD is paid for the balance of the employee’s life, but the State Fund or the self-insured employer is allowed an offset for the amount of Social Security benefits the employee receives. PTD benefits are referred to as pension. The injured employees drawing a pension also get an annual cost of living increase. There is no provision in the state workers comp law for a settlement of PTD claims. Therefore, the Washington State Fund has a funding problem now with half of all workers comp payments going to people drawing lifetime pensions.

In an effort to reduce the amount of money being paid for PTD, effective June 15, 2011, workers who are age 55 or older have the option to negotiate a settlement agreement with periodic payments rather than staying in the work comp system or being retrained for another job. The workers who opt for the settlement agreement will continue to be eligible for medical care.

Death Benefits

The burial expenses in Washington State are covered for a work-related death up to $7,709.32. The death benefits for a dependent spouse are 60% of the average monthly wage plus 2% for each dependent child up to 5 children. The maximum and minimum amounts follow the TTD guidelines. There is no lifetime maximum amount or dollar maximum for death benefits. If the spouse remarries, the spouse receives 24 months of death benefits or the lifetime annuity value, if less. Children receive benefits until age 18 or until age 23 if a full-time student. Disabled children can receive death benefits beyond the age of 18.

Vocational Benefits

Washington workers compensation law also includes discretionary vocational benefits (the State Fund or the self-insured employer determines whether or not they will offer vocational benefits). Vocational rehabilitation is in the best interest of the employer and the employee as placement in a new job reduces or eliminates the amount of PPD that will be paid, and stops the employee from making a claim for a lifetime pension (PTD). (WCxKit)

If the injured employee is unable to return to their prior job due to disabilities from the on-the-job injury, and the employee does not have the skills for a different job, a vocational counselor can be assigned to work with the employee. If the employee declines the vocational counseling, medical and indemnity benefits can be terminated. The vocational counselor will develop a training plan that is reviewed and approved by the Department of Labor & Industries. The vocational plan includes a job goal based on the employee’s skills, interest and medically documented limitations. It can include schooling or on-the-job training for up two years.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact:RShafer@ReduceYourWorkersComp.com or 860-553-6604.

Ireland’s Minister for Agriculture, Marine, and Food, Simon Coveney TD, called on farmers and those who work in the agriculture sector to foster safety at the National Conference on Health and Safety in Agriculture this June, according to a report from Ireland’s Health & Safety Executive (HSE).

“The challenge that we face is to change behavior and attitudes so that safe working becomes second nature. In recent years the number of fatal accidents in agriculture has been higher than in any other sector,” Coveney said. “The industry is expanding and creating new jobs and this is to be welcomed. However, we don’t want to see a corresponding increase in lives lost.”

Martin O’Halloran, CEO of the Health and Safety Authority, echoed the minister's concerns about the potential for further increased accidents in agriculture and related industries. “As the activity level in agriculture increases so does the risk of increased fatalities, injuries and work related illness,” he said. “We are committed to working with the key players in the agriculture sector to reduce fatalities, accidents, and work-related ill health. This approach of working in partnership with the strategic partners has been proven to work in other sectors such as construction.”

John Bryan, IFA president, chaired the proceedings and reaffirmed his support for the Farm Safety Partnership in promoting increased awareness at farm level. “The Farm Safety Partnership has real focus on the key issues and has introduced initiatives in the areas of tractor safety, child safety and livestock safety. Each of these is important in delivering the overall safety message. There must also be an emphasis on getting information to older farmers, who are particularly vulnerable," he said.

Coveney launched a new HSA guide, Guidance on Safe Handling of Cattle on Farms, at the conference. The guide was developed with assistance from members of the livestock safety working group of the Farm Safety Partnership.

The Teagasc Research Centre also provided valuable data for the guide.Teagasc director, Prof. Gerry Boyle said Teagasc is committed to continuing to work in partnership with farmers through Ireland's Farm Safety Partnership. “I would appeal to farmers to use our advisory and training services for health and safety to improve on-farm standards and practices,” he said. “We are currently conducting seven research studies related to health and safety in agriculture and we will then ensure that these findings are implemented at farm level.” (WCxKit)

Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com .

DISCLAMER: Do not use this information without independent verification. All state laws are different and change frequently. We do the best we can to provide up-to-date information but do not guarantee it is always perfect. Consult with your corporate legal counsel before implementing any cost-containment program.

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